PI project: Hepatitis B prophylaxis in patients with malignancies Natasha Banerjee

The problem Estimated 240 million people have chronic HBV infection Patients with CHRONIC Hep B infection OR prior Hep B infection are at risk for REACTIVATION when exposed to immunosuppressive therapy REACTIVATION can lead to acute hepatitis  liver function impairment  liver failure  DEATH REACTIVATION can lead to hepatitis  DELAY or termination of curative cancer treatment 20-50% of patients with HepBsAg positivity and 3-45% with HBcAb positivity develop reactivation with cytotoxic chemotherapy

Who should be screened? Most guidelines recommend universal screening of ALL patients before cancer therapy NCCN and the CDC recommend “any patient who is expected to receive IST or chemotherapy should be screened for HBV, HCV, and HIV prior to treatment.” Who should especially be screened? Patients undergoing intensive immunosuppressive therapy, including HSCT or therapy for leukemia or lymphoma All patients who will receive rituximab/B cell depleting therapies

How to screen?

Labs to order HBsAg HBcAb (TOTAL, NOT IgM!!) WARNING: acute Hepatitis panel checks HBc IgM ONLY IF positive for HBsAg or HBcAb HBV DNA PCR (viral load)

Chronic Hep B infection Chronic Hep B Pattern: POSITIVE HBsAg (negative indicates cleared/resolved infection) POSITIVE total HBcAb Vaccinated against Hep B NEGATIVE HBsAg POSITIVE HBsAb NEGATIVE HBcAb

WHO receives prophylaxis? HBsAg positive or detectable HBV viral load HBsAg NEGATIVE, HBcAb positive More important if going to receive rituximab or undergo HSCT Can also monitor viral load q3mos and initiate if VL becomes detectable

How to prophylax Approved nucleoside analogues: Lamivudine (high rates of resistance, 80%) Tenofovir (nephrotoxicity) Entecavir (low resistance, 1.2%, no significant side effects) 0.5 mg daily

How to monitor During chemo, monitor HBV viral load monthly, then q3 mos after treatment completed Continue prophylaxis at least 6 months and up to 12 months after completion of therapy

How do we do? Chart checked all fellow patients seen in 2 Monday clinics in Jan 2016 4/5 CML patients never had hepatitis labs checked Two PV/MF patients never had hepatitis labs checked 1/4 myeloma patients never had hepatitis labs checked One T cell lymphoma patient had labs done correctly 1/3 follicular lymphoma patients had labs done correctly One Hodgkins lymphoma patient had labs done correctly One T-ALL patient had acute panel done only One DLBCL patient had acute panel done and was negative, then HBcAb total done and was positive, VL not checked, was not started on ppx